Episode 17, Season 2. Chuck and Chris introduce a new segment: deep dives on surgical technique. We start with the most basic and yet important procedure in hand surgery, carpal tunnel release. We share our mini open approach to release the transverse carpal ligament. And then we pivot to discuss the setup and execution of wrist arthroscopy.
Let us know if you like this segment and we welcome suggestions on other procedures to dive into.
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Survey Link:
Help Chuck and Chris understand better what you like and what we can improve. And be entered for drawing to win a mug! https://bit.ly/349aUvz
Episode 17, Season 2. Chuck and Chris introduce a new segment: deep dives on surgical technique. We start with the most basic and yet important procedure in hand surgery, carpal tunnel release. We share our mini open approach to release the transverse carpal ligament. And then we pivot to discuss the setup and execution of wrist arthroscopy.
Let us know if you like this segment and we welcome suggestions on other procedures to dive into.
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Survey Link:
Help Chuck and Chris understand better what you like and what we can improve. And be entered for drawing to win a mug! https://bit.ly/349aUvz
Welcome to the upper hand where Chuck and Chris talk hand surgery.
Chris Dy:We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.
Charles Goldfarb:Thank you for subscribing wherever you get your podcasts.
Chris Dy:And be sure to leave a review that helps us get the word out.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:Doing well today? How are you?
Chris Dy:I am doing well. It's a beautiful day in St. Louis. It was perfect spring weather this morning. Absolutely perfect.
Charles Goldfarb:It's spring. And you know, it is remarkable. The grass is green and the trees are blooming and the flowers are blooming. It does, you know, further kind of make us feel good about coming out of this pandemic. Just the the optimism of a spring renewal.
Chris Dy:Yes, yes. You know, my son did his first tennis lesson this this morning. And I was optimistic and got the jogging stroller out and I forgot about the sneaky hills in our neighborhood trying to get to the tennis courts. And I think I'm gonna be feeling that one tomorrow. But yeah.
Charles Goldfarb:You mean with all your Pelotoning you weren't ready for a few little hills?
Chris Dy:Oh, well, it's not like I was on a bike. I was running this time. But it's good. It's good to mix it up as you know. I guess one day we'll probably get that peloton trend but um, stick with the bike for now. So they're they're they're they're not cheap those pelotons.
Charles Goldfarb:They are not, they are not. So we have a lot to talk about. Let's jump right in. So is there a any comments or reviews or anything to share?
Chris Dy:Yeah, we have a great survey comment. And this one is one that was left from Spain. So thank you, to those of you that are listening overseas. We enjoy having you, as part of our podcast community. And the comment is Thank you for taking a bit of your valuable time to spread the word and share with us your experience and information. Please don't put it to the side. So well. We're happy to do it. The comments like that are what keep us going. Please, everybody leave a review on iTunes, download, subscribe, all that kind of stuff. I did talk to a patient about the podcast this week in clinic because they're asking questions, I downloaded an episode for them. And I might have left a five star review. I might have. A rating not a review, I told them I was gonna do it. They they chuckle at the idea.
Charles Goldfarb:That's pretty fun. So you use the podcast as a resource for the family?
Chris Dy:Starting to, starting to because they ask and I'm like, well, you can hear us talk about this, you know, it's obviously a very different format when you're talking to them in the office as their physician, but some patients I kind of get the sense that they wanted to hear especially the Dupuytren's thing is really helpful to be honest with you.
Charles Goldfarb:Yeah, I think of all the all the episodes that might be the most helpful.
Chris Dy:You know, one of the things that a little passion project I have for our Plexus patients is trying to develop this idea of a coaching program, and a care navigator, which you often see in a lot of oncology settings. And just Plexus is so hard because it's such a devastating injury in so many ways. You know, first off, you know, it's it's hard to understand, you know, the, the actual medical content of what's going on, you know, so we tell them things, we try to explain the plexus, show them the anatomy sometimes, and then talk to them about treatment options, etc. But once you say the word surgery, like their, you know, eyes glaze over and you know, you don't know how much they're retaining. And then there's all of the social things that come with it. You know, oftentimes, this means like loss of a job, loss of an income for a family, filing for disability, all the things that come with it. And it's just so hard for patients and their families. So we're trying to figure out a way to develop a coaching program. And step one is to develop this journey Guide, which we've been trying to put together. And we we put it together based on some information from some of the qualitative interviews we did with Plexus patients. And I think it looks great. Our marketing team helped us put it together make it look really nice. And we're doing some pilot testing now hopefully a grant that we've applied for, Anna Scorvall is going to come through at some point. And it's going to be fun. We're going to partner with the United brachial plexus network, like we've talked about in past episodes of working with patient advocacy organizations to work on education.
Charles Goldfarb:Love it, love it, it is always interesting that this is never going to be paid for or funded by our insurance companies. And so seeking grant funding is probably the only way forward but you know, that's what that's what the value of the setting were and taking advantage of those opportunities, I believe.
Chris Dy:Absolutely. Well, Chuck, we have to do a drawing. I didn't want to forget but you are in charge of drawing you went kind of high last time so can you pick a number between one to 90.
Charles Goldfarb:Yes, it would give me great pleasure to send out another mug. Why don't we go with number 21.
Chris Dy:Ooh kinda low.
Charles Goldfarb:Yes, who is that?
Chris Dy:Okay, if your name is Jesper Nortonsgold. I don't know if I correctly got that please email us handpodcast@gmail.com and tell us how to collect your mug. And then also, if you anybody ever wants to fill out the survey, it's in the show notes. That's your way of entering to win a mug and we'll go high next time remind me that Chuck.
Charles Goldfarb:I definitely will I definitely well, fantastic. So why don't you want to you want to explain what we're gonna do next?
Chris Dy:Yeah, I thought it'd be kind of neat to do a very surgical technique driven episode, you know, maybe make this a recurring segment. Did you ever watch that show on ESPN called Details?
Charles Goldfarb:I did not.
Chris Dy:So it was basically Kobe and then eventually like Peyton Manning, like breaking down film with people and really kind of getting into the weeds on stuff. And I would love if we could look at film together the GoPro surgery stuff and kind of break down techniques stuff, because I'm a nerd about that. And I think that's the wave of the future in terms of how we're going to teach residents and stuff, obviously very hard to get there. But we can at least talk about some of the really nitty gritty stuff that goes into a case, as if we were, you know, taking you through a case if you were our trainee. And then hopefully, if you're not a surgeon, and you're a hand therapist, you'll at least get to hear how we think about things when we're in the operating room. I thought it'd be kind of neat if we started with a very basic level case, and then also a more advanced level type surgery. And we can just really get into the weeds on it. And hopefully, this resonates with people. So I know you didn't want to initially do this, because it's probably a little too basic. But let's start with something as simple as a mini open carpal tunnel release.
Charles Goldfarb:Perfect. So we're not going to talk about indications. We're not going to talk about anything. This is very practical based discussion of how Chuck and Chris think about this actual procedure, correct?
Chris Dy:Yeah, exactly. So we've already talked about all of the other things in terms of indications and anesthesia
Charles Goldfarb:It's interesting, because you led our techniques. So leave all that out, say if you're doing local owner, you've already done a block. If you're, you know, if the patient's having a Bier block, they're already you know, had that done, or if they're fully asleep, they're fully asleep. So you've got the patient prepped and draped, how do you decide, you know, where you're going to put your incision or what kind of incision you're going to make? group in a discussion of the critical steps of things like carpal tunnel releases, and so I don't have that in front of me, but that certainly can guide this discussion. So the first thing is, where do you place your incision, right, you know, your setup, there's a hand table, so you're resting your arm and an abducted position, and the hand's resting, I use the place a towel to slightly extend the wrist, and I make a two centimeter incision. My skin landmarks are typically I'm along the radial blur of the ring finger began about one centimeter distal to the wrist crease. And I do assess the location of the hook of the hamate, and the thenar eminence, but pretty central on the palm, just distal to the wrist crease. And I've been very happy with that approach. What do you think about
Chris Dy:Two centimeters? Did you always start with two centimeters when you came out of training? Or did you eventually get there?
Charles Goldfarb:I think I always started there, sometimes there's a little smaller, sometimes a little bigger, it's rarely significantly smaller, because it has to be big enough to get the retractors in. And for me, the retractors are always the same. There's two Senn rakes and one Ragnell rake. And it's just this is one of those procedures is highly reproducible. You know, every patient is a little different. There's the big beefy worker's hand, there's a smaller for lack of a better expression, little lady hand, and there are differences, but essentially, it's a very reproducible surgery, I believe.
Chris Dy:So the two centimeters basically the width of the, of the rake portion of a center retractor right?
Charles Goldfarb:Yep, give or take a little bit. That's exactly right.
Chris Dy:Okay, so I go a little bigger than that, you know, I've just found in my experience, especially with teaching, I've needed a bit of a bigger incision. So I'm about four centimeters. So you know, sometimes a little bit smaller and like you've seen a little lady hand and then in the worker hand, bigger hand, bigger incision. I'm not shy in my incision. So maybe one day I will get to Goldfarb level, Kobe level of technical mastery, but you know, it's a carpal tunnel release, right? You've got you got to get it right 100% of the time. You know, you can't you can't miss the layup.
Charles Goldfarb:No, you can't miss the layup and you do have to get it right. And I would say your point is, is absolutely right, making a little longer incision. It really has no negatives. And so if you're struggling for visualization and for safety, and that typically would be distally struggling, I always make a longer incision. So I try to work through the incisions, essentially, you're working through windows with a small incision, you're looking straight down, then you're focusing on distally and then you're focusing on proximity. So there's really three windows of work, which is honestly just a little harder with a small incision, but but I think once you get used to that technique, It's not hard, and it's quick.
Chris Dy:Now do you ever you place your incision right in that kind of that concavity between the thenar eminence and the hypothenar eminence, or, you know how I was one way that I've learned to minimize my risk to the palmar cutaneous is to go just ulnar to that, based on some of the anatomic studies that I think Dr. McKinnon led.
Charles Goldfarb:I think a little ulnar is fine, mixed with I would like to be a little radial to the hook of the hamate. Now sometimes hook at the hamate is easy to palpate. If it's not easy to palpate, I make the assumption that it's sitting where it should be sitting, which is one centimeter distal and one centimeter radial to the pisiform. And those landmarks can be drawn. And it often is in that sulcus, but going a little ulnar to that sulcus and again, a little radial to hook at a hamate, to me is a safe area. And it gives you great exposure and again allows for a rapid approach. Do you ever cross the wrist crease? Almost never it would be in a traumatic situation where I had to because of safety. Or if I was also performing a distal ulnar tunnel decompression, and I need to find the ulnar bundle proximal to the wrist, which doesn't mean I do it every time. But that would be a consideration.
Chris Dy:Yeah, I think that I've found that in the cases in which you're doing an acute carpal tunnel release for say in the setting of a bad distal radius fracture or something like that. In that patient who's typically a younger patient, they don't have carpal tunnel syndrome, you know, ongoing chronic carpal tunnel, they've got really a lot of swelling, and it's that volar antebrachial fascia that I think you truly need to see and completely release. And in that setting, I routinely will cross the wrist crease with a Bruner zigzag, but outside of that I usually don't.
Charles Goldfarb:But here's the negative of that, right, I recognize the positive and I completely agree with you, there is a big negative when you make an incision in the palm only, or if you make an incision in the distal forearm only, you can expect rapid, complete healing usually in a beautiful fashion. When you cross the wrist crease, everything changes. And that zigzag incision is appropriate. But it doesn't mean the patient will not be symptomatic. And so symptoms from that where you cross the crease can be really problematic and can really slow. A patient getting completely over the surgery.
Chris Dy:Yeah, absolutely. I agree with you 100%. And I think certainly some of our therapy colleagues can tell us about that too, because I'm sure they spend a lot of time with patients trying to work through that issue. So I agree it's not a complete freebie by any means. And I think that's important to consider.
Charles Goldfarb:So talk through you make your skin incision, you place your retractors talk through getting down to and exposing the transverse carpal ligament.
Chris Dy:So enough of a skin incision so that I can insert the senn retractors on each side. So when I'm doing this, and I think you know, mainly it was because of the way that you and others have taught me. I'm just if I'm the surgeon, I'm holding the knife and I'm right handed, I've got the knife in one hand and I've got a senn retractor in the other hand, and the person across from me is also using a senn retractor there. Once I go through the skin and I'm visualizing the superficial palmar fascia, I will oftentimes use a ray tech either holding it with the forceps or putting it there and then pulling it back distally with the Ragnell retractor, to clear off any residual subcutaneous fat off of the superficial palmar fascia. The assistant whether that's me or the resident, or the fellow, usually I'm the assistant to be honest with you, is holding that Ragnell in there distally the superficial palmar fascia is completely visualize now in the wound, and then I start releasing incising that superficial Palmar fascia with the knife with the idea of then exposing either the transverse carpal ligament directly or seeing those thenar muscles in some patients that run over the transverse carpal ligament. What about you?
Charles Goldfarb:I think that's well said I think about this operation as a collaborative operation with the assistant assuming it's a surgeon of some variety, where he or she is doing part of the operation. And I'm doing part of their operation. Obviously, I'm overseeing the entire operations that whoever is sitting in the best position is responsible for that step. And, you know, patients often say, you know, will you do 100% the operation? And my answer is typically, you know, that's not how I do it. Of course I can, but I think the best way to do is how we always do it and that is myself and typically a fellow working closely together to get this done. And my responsibility is keeping everything safe. And I think one of the pearls of this is I am always looking for an aberrant nerve branch. Any type of radial I'm sorry, any type of median to ulnar interconnection, whether that be more predominant when you have a lot of muscle directly over the transverse carpal ligament or not. But I'm always looking for that to minimize risk of an adverse event.
Chris Dy:Exactly like like you know, it's it's a carpal tunnel you got to get right every time that there are little Things that might come up along the course of that surgery that can, can lead to the outcome you don't want.
Charles Goldfarb:Exactly. And then I'll take it. So you have us now expose, we're looking, we've gone through the Palmar fashion, we're looking at the transverse carpal ligament, we're exposed, I typically incise the transverse carpal ligament with a 15 blade, and then I work typically with scissors distally, first, to expose that bright yellow fat adjacent to the superficial palmar arch to assure that we have a distal half complete release.
Chris Dy:So it just from a practical setting, I remember I think it was you that taught me this, but I use this with trainees in terms of where you're sitting, it's typically for me, the trainee is the one who is quote, going distally with the release, and I'm the one who's going proximally with the release, is that consistent with what you do, and how did you get there?
Charles Goldfarb:That is how I think about it. And that is how I typically proceed is because I can believe I can provide perfect exposure for a simplistic release of that transverse carpal ligament distally. And while we know that risks to neurovascular damage are greater distally in my mind, there's greater risk proximally. And so I would rather be the one to work proximally and release the distal forearm fascia and the proximal transverse carpal ligament myself.
Chris Dy:So your point about releasing the transverse carpal ligament, that's a you know you're doing it with a scalpel to start. That's a complete tactile part of the operation. And I think that that is a harder thing when you're working with less experienced trainees for them to pick up. And I think it takes repetition and caution as they're doing it, I typically will ask for a new 15 blade at that point, because I want a new knife when we're releasing the ligament. And like you I do it just radial to the hook of the hamate. And you have to be careful not to slide into Guyon's canal. And that's that can happen if the forearm or the palm is not completely flat on the table. And so that's the responsibility of the person sitting on the radial side to keep it flat. And oftentimes, that's done with the shaft of the senn retractor that is now progressively gotten deeper. And when I release the transverse carpal ligament, I typically tell the trainees to start in the middle of the ligament where it's the biggest I remember Dr. Gelberman used to make us memorize all the thicknesses and where it was proximal, middle, distal, all that kind of stuff. And while I don't necessarily need you to know all of the numbers, I need you to know where it's the thickest, because that's where you're the safest as you're doing this tactile part of the surgery. Then your point about looking for that, you know, the bright yellow fat. Peter Stern's article showed us that once you see that fat you've got about two more millimeters of ligament left. And that's when obviously you get the Ragnell retractor that's sitting at the the apex of that incision deep pull that fat back release that last part of the ligament. And for me, that distal third of the ligament is released with tenotomies.
Charles Goldfarb:Yeah, I completely agree with how you said it. And it's about visualizing release, it's also about palpating. And, and so placing scissors distally. And just lifting up to make sure you have a completed releas is vitally important. The other thing that I think you alluded to, you know, is is using your retractors to maximum benefit, the retractors are not meant to only bring the soft tissues away, there's two other benefits. One is flattening the palm. And the second and I would say major benefit is applying tension to the transverse carpal ligament. And that's really important. And so people talk about different ways to get through the through the ligament. And when attorneys are involved, you hear them talking about oh, my gosh, he or she the surgeon didn't do this or didn't do that. Really, if the transverse carpal ligament's under tension, releasing it with a with a knife is fine. I think the risk is incredibly low. And some people talk about you got to get something under the ligament protection wise. I don't I think you can. But I don't think that's necessary. I think actually poking through and trying to depend on a cutting on the top of a mosquito clamp, for example, doesn't improve your safety, I just think you have to be cognizant, and I think that risk is extraordinarily low.
Chris Dy:And, you know, you mentioned the use of the retractors to keep things on tension, you know, so there are cases in which you know, when we incise the ligament, perhaps we haven't incised it in the area that we want to to start. And sometimes that you know, you don't immediately see the release that you think you should see doesn't pop open the way you want it to usually means you're too ulnar. And it's important to make sure that you course correct and translate that that incision and the transverse carpal ligament more radially. But when you lose that resting tension in the transverse carpal ligament, that becomes a little bit technically harder. to course correct. You know, sometimes it's easier to maybe work a little more radial and a little more proximal, in terms of getting that getting that ligament released.
Charles Goldfarb:Yeah, absolutely. Well said and then just to finish it off, you know, when you work proximally I try to create a tunnel. And I should say that all this was as taught to me, as well as some of my partners by Tom Kiefhaber in Cincinnati, that you can use the long end of the two senn retractors. And the Ragnell retractor to create basically three, three pieces of a tunnel and the bottom of your tunnel is the transverse carpal ligament. And you can spread and have perfect visualization of that forearm fascia, and then you release it now some people will talk about sliding versus cutting. I don't think it matters as long as you have safety and visualization to me, it's about the visualization piece. And then you just release it. And I I love that technique, I think you can easily go well across the wrist crease proximally. Even if your incision stops, you know, again, a centimeter distal to the wrist crease.
Chris Dy:Yeah, I think I agree with you. I actually affectionately call it the box of Calfee what you're describing, because Ryan makes a point of you know, setting that up perfectly. Not that you didn't but you know, he just we always talked about the box, I picked the box, right. So, so released, and then I typically will take one thing that I've learned to get better at is using the tip of the tenotomies as an extension of my finger and really getting better about feeling with the tenotomies. He talked about how this distally that's also how you feel your release, but then also proximally, doing the release and using the closed tip of your tongue anonomys in this case for me tips up feeling the skin, running it back into the palm wound, making sure everything's completely released. And oftentimes when patients are awake, I will show them like, Look, this is how far we worked. You can see the incisions only this big, but we went you know, back and forth. And this is how far your nerve is released.
Charles Goldfarb:Yeah, well said. Love that. And then I just closed skin. I don't know about you. I played around with different closures. I like-
Chris Dy:Hold on hold on before before you go to skin closure. Do you look at the nerve?
Charles Goldfarb:No.
Chris Dy:Do you think that there's a role? I mean, you know, there's obviously been a number of older studies that have clearly steered us away from doing any sort of neurolysis of the median nerve. Do you ever think there's a role for looking at it?
Charles Goldfarb:I think if there's a previous nerve injury, or you're exploring for something other than a straightforward carpal tunnel release, yes. And I think Susan MacKinnon and Richard Gelberman independently taught us not to do that. Because all that does is create more scar tissue. And so looking at the branches distantly looking at the motor branch, I see no benefit. And sure I when I open the transverse carpal ligament, I will check and see if the median nerve is sitting right beneath me. And, you know, you can call it hyperemic and you can examine it, it doesn't do anything doesn't help you. And I think it only potentially harms the patient to do too much with that nerve. So I do not do you?
Chris Dy:I don't based on like you're saying, you know if there have been multiple papers from legendary surgeons who have taught us not to do that, and you know, I don't see a role for that. In a revision setting, I typically will expose the median nerve proximal to the wrist crease in order to provide safety. And that's a whole different discussion. So I'll visualize it there. And then if you read some old texts, like old chapters, they talk about patients with thenar atrophy doing a neurolysis of the recurrent motor branch and you know, all that kind of stuff. I don't do that. I don't think it's necessary, like you're saying increases the risk in closure.
Charles Goldfarb:I've experimented I know some people like monocryl and some people like buried stitches, and I use two or three horizontal mattress 4-0 nylons, I've been really happy with that most patients, most patients heal beautifully. With a couple rare exceptions where there's some, you know, train track appearance, but in general, it's a beautifully healed wound. And I think the suture irritation complications we sometimes see are non existent. It's I've been really happy with that, what do you do?
Chris Dy:Same thing. And then I typically will have them take their dressings down day three or day five. They're soft dressings, you know, no splints or anything, which again, is historically been done, leaving the wrist free, essentially leaving the fingers and the thumb free. And then let them get it wet to three or five days. And then they cover with the band aid.
Charles Goldfarb:Love it. Love it. Alright, let's pivot.
Chris Dy:Okay, so that was a really in the weeds on carpal tunnel. I remember I gave a talk at a at the University of Michigan about 14 months ago, like pre shutdown of everything. And I realized I spent about 30 minutes talking about how I do a carpal tunnel. They probably did it for I don't know if they did, but they played along so. So let's talk about something that is near and dear to your heart. And I'm going to honestly pepper you with more questions than probably you're going to ask me, let's talk about how to set up and do an effective wrist arthroscopy. So leave out the details on like the whatever other pathology you're treating like an SL or tfcc or whatever, but Let's just get to how you do a tfcc or a wrist arthroscopy. How do you set up the room?
Charles Goldfarb:Yeah, so, first of all, the arthroscopic tower is at the foot of the bed. There needs to be a hand table with a leg for stability. And you need to have a traction tower have some variety and there are different varieties. I think it doesn't matter a bit. For an arthroscopy, I happen to use the Linvatech traction tower. I've used the arc traction tower as well. But it linvatech is simple. It's been around for 30 years, it works just fine. You use finger traps on-
Chris Dy:Can I pause for one second.
Charles Goldfarb:Yeah.
Chris Dy:If you are new at doing wrist arthroscopy, or you're a trainee, and you're, you're using the linvatech tower, there is a fantastic video on YouTube about how to set up the tower. A it's incredibly useful for you and for your staff. B it is so 80s It's awesome. I can just imagine the VHS tape that it came on initially. But it is incredibly useful.
Charles Goldfarb:It's a valid point. Because if you're with an inexperienced team, and you have to put it together yourself. You know, each year our fellows have to learn how to put together the tower. And that's part of the process. So you're right, it should be easy. It is easy. Once you figure it out, it's not a big deal. Finger traps too, I usually use only two fingers, you can put finger traps on all four fingers, it doesn't matter 10 to 12 pounds of traction. So let me just talk through the basics. Number one, every patient gets an exam under anesthesia, to assess primarily stability of the carpus instability of the DREJ. I think that's really important. Number two, you exsanguinate the arm. Number three, you put the hand in traction with finger traps, padding, and use the straps that come with the tower to apply 10 to 12 pounds of traction to the fingers. And that's your basic setup.
Chris Dy:So you said exsanguinate, which implies that you have a tourniquet. So is this a non sterile tourniquet above elbow?
Charles Goldfarb:This is a not, well... some people describe doi g this without a tourniquet. A d some people definitely do th s without fluid. I actually sti l use fluid for a lot of reason. And I use a tourniquet and t e tourniquet is as high on the a m as you can place it. Because f you have a short arm, or y u place the tourniquet t o distally it gets in your way f getting a 9090 with yo r shoulder and your elbow at 0 degrees. And so you want t e tourniquet place as high as y u ca
Chris Dy:Now do you have a strap then placed over the tourniquet to provide counter traction or to stabilize the brachium as you are pulling traction through the tower?
Charles Goldfarb:Most of the systems come with three straps one is originally designed to put around the hand table which I do not use. So I use two straps, one holds the forearm to the tower. And the other holds the arm as you just implied to the tower. And so two straps give us plenty of support and give you a great setup.
Chris Dy:Okay.
Charles Goldfarb:And then so basically, when you're doing a scope, the hand is the shoulder is 90 degrees abducted, the elbow is 90 degrees flexed, you're standing looking at the dorsum of the hand, which is resting against the tower. And then you make your portals and so there's I'm not gonna get into the debatable stuff. But basically, everyone uses the three, four portal, and that is called the three four portal because it's between the third and fourth compartments, just distal to Lister's tubercle. There's a soft spot. And you can needle localize but most people don't make a small incision, you bluntly spread with a mosquito type clamp down to and through the capsule and place your scope in the joint. So that's step one.
Chris Dy:So do you do you still draw on the dorsum of the wrist and all that kind of stuff. And I was always taught to draw when you're in traction not to draw before your in traction.
Charles Goldfarb:So I do draw mainly for the benefit of the team. And you absolutely have to draw after your in traction because your skin position changes. So draw after your in traction. I used to insufflate the joint like one might insufflate an elbow joint prior to an elbow arthroscopy, I no longer do that, because I don't believe it adds anything it doesn't add safety. And the elbow, you insufflate the joint to increase the distance between the bone and the neurovascular structures. And the wrist, it doesn't accomplish the same thing. So I simply put my scope in the three four, I put a needle to localize my 6R portal named because it's just radial to the ECU tendon. And then I create a 6R portal in a similar fashion, sharp incision to the skin only blunt dissection down to and through the capsule. And then I place either a shaver or a probe or whatever I need to start the wrist scope.
Chris Dy:So for your when you're inserting your three, four portal and you're starting your portal, I think it's important to recognize that you need to match the native tilt of the articular surface, because if you don't, you're going to be, you're not going to get into the joint. And you're probably going to work your way into some cartilage that you don't want to work your way into.
Charles Goldfarb:That's right. And that's the hard thing for trainees to learn is how much pressure can you put on that capsule to pop through and not have any collateral damage or iatrogenic damage to the cartilage. And so, you know, we usually do put the wrist in slight flexion. And I usually try to work with a curved clamp and, and envision myself coming over the top of the dorsal radius falling into the joint, but that's a great point. Likewise, when one is going to examine the mid carpal joint, it's harder, it's a smaller space, it's harder to get into the joint. And it requires just experience more tactile experience of what does the capsule feel like? What does a contracted capsule feel like? And what does the capitate head feel like so you don't want to injure it?
Chris Dy:When you do your mid carpal portal, are you using the same skin incision that you use for your three four, or are you making a separate skin incision,
Charles Goldfarb:I use the same skin incision, the skin is so pliable that it's not a big deal. But it's not meant to be a big deal if one wants to make a separate incision. And really what we're saying is that midcarpal joint has two portals is a radial mid carpal portal, which could also be your three four incision and an ulnar mid carpal portal. I don't use a four five portal for the radiocarpal joint. But that four five portal could also serve as your ulnar mid carpal portal if you can imagine a big one centimeter distal, because I'm a little more radial with my primary ulnar sided portal, which is the 6R portal I'm sorry, I said that wrong. Because I'm a little more ulnar with my 6R portal, I do not use that to access the mid carpal joint. So when I need an ulnar mid carpal portal, I make a separate incision after needle localized.
Chris Dy:So talk me through you know, you've got your three, four portal, you're visualizing through the three, four and you've established your 6R, take me through the diagnostic arthroscopy at that point.
Charles Goldfarb:You know, and from our knee colleagues, or I should say our sports colleagues, I've learned that you should do these kind of procedures, maybe like we do everything in a very standardized fashion. So you want to do your diagnostic arthroscopy the same way every time, you don't want to miss something. And so first, you look at the radial side of the wrist, whether that be the cartilage on the radial, the distal aspect of the radius, and the scaphoid facet and ulnar facet. The SL ligament, both the ligament test to volarly and the dorsal SL, which is kind of distal to your incision, you want to look at the volar radiocarpal ligaments, most notably the radioscaphocapitate, the long radiolunate. And then you want to continue ulnarly looking again at the cartilage of the lunate, facet and the proximal lunate, the tfcc as you get more ulnarly, and the various components of the tfcc are just really important to assess.
Chris Dy:And then after so say then you've made your decision, you know, say for example, you're there to assess the tfcc How do you do that?
Charles Goldfarb:So let me make one point so don't forget to say it, you cannot see the LT ligament or will really assess the triquetrum through the three four portal to evaluate the LT ligament and really assess the triquetrum you have to visualize to the 6R portal, you just can't get around the corner, so to speak. Having said that, I find it much easier to assess the tfcc from the three four portals. So that's your viewing portal. And really, you're looking at a few different things. First of all, you're looking at the trampoline sign, which is a very subjective way to assess tension of the tfcc. You're looking at the volar ulnar carpal ligament to assess for a split tear as our Mayo friends emphasize, I think it's very uncommon. But there can be fraying or degeneration volarly. You're looking dorsally beneath the ECU tendon sheet because we know that's where peripheral tears can happen. And you're also finally looking for what's increasingly become apparent, which is a foveal tear. And so the foveal tear is really a subsurface tear of the tfcc where the dorsal and volar radial ulnar ligaments attach to bone. And so I think for many years, I was guilty of not understanding that anatomy and not understanding that that is a really important part of our assessment. The final tear is the central tear, which we've always thought of as degenerative, and we have new research, which is really making me question that because I worked with Sanj Kakar at Mayo, and we identified a large number of patients that have a coexistent central tfcc tear and foveal tear, which really is kind of, you know, really kind of hand weaning kind of way mind blowing because they just shouldn't go together, but yet they are really common together. And Sanj and I were just talking this week, the number of times I do a foveal repair, compared to a peripheral repair has been flipped on its head. So it used to be 10 to one peripheral repair versus foveal repair. And now it's 10 to one the opposite direction it's really unbelievable and interesting.
Chris Dy:So how do you assess for foveal tear? You mentioned a trampoline test, which is a classic, you know, classically described. And I know that you've done a lot of work with the hook test. So A can you first tell us how to do a trampoline test. And then can you, you know, what instrument used to do that, what it should look like, what it should feel like, and then also how you do a hook test.
Charles Goldfarb:I want to tell you about four tests. But first, let me say your first obligation is to make sure there's no synovitis or fraying, which is obscuring your vision. And that's most importantly, in the prestyloid wrist recess, which is straight ulnar, and also dorsal and ulnar. So you clean up the wrist to make sure you have a true visualization. So first test is the trampoline test, again, very nonspecific, you have to do a lot of wrist scopes to understand what's normal and what's what's not normal. And if it's basically it should be like bouncing a quarter on a military made bed, right, it should just be nice and rigid. And if it's too floppy, you have to ask why is there a peripheral tear? Is there a central tear you hadn't picked up yet? Something like that?
Chris Dy:And where where do you do that test on the tfcc?
Charles Goldfarb:Kind of back and forth from volar to dorsal in the middle? Okay. But again it's so nonspecific, that I it may not be helpful, but if it's soft, it just makes you reassess everything. Look for tears. And you just question Why is it not as rigid as it should be? So that's number one. Some people talk about a suction test where you put a shaver in, turn on the shaver and see if the TFC remains flat, or whether it's drawn towards the shaver.
Chris Dy:We have suction on, the section on the shaver, you turn on the shaver.
Charles Goldfarb:Yes, turn on the suction on the shaver. Thank you. And so if indeed, the TFC rises, it implies there's subsurface tear, becaus the tfcc should not be abl to do that. I think it's an ok y test is easy enough to try. But it doesn't dramatically elp me most of the time. Third est is the hook test, wh ch was described, I believe, We have to get your heart rate back down. You sound really by the folks at Duke Dave Ruch nd others, and Samir Treyhan l d a study at our institution, ooking at it more care ully. And basically, it's a way f putting the probe or the h ok of the probe around the very lnar side of the tfcc. And lifti g up, and you really shouldn't e able to do that. And if y u can get under the TFC and lif up, then that's a positive test. And again, I have foun more and more of those to be positive, based on you kno, the the scopes that I do. An then the last test is trying to get under the tfcc. To visualiz, you can do that with a DREJ sc pe. And I would say that' really challenging. And t's not something I routinely do. You can do that by making a traight ulnar incision, the s called 6U incision. But that' a little perilous, because ou have that sensory branch of he ulnar nerve. If you choose t at approach, you put your scope nd just drive right under the tf c. I rarely do that. But wha's been interesting is when I h ve a central tfcc tear, you an drive your scope from the thr e, four portal under the tfcc, to look at the head of the uln, and understand the insertio, which is really sup r interesting. And again, gets o this concept of these coexiste t tear excited right now we got to let you calm down. This is the good stuff. Man. I I enjoy this for sure.
Chris Dy:Yeah, if listeners, listen to the enthusiasm compared to the carpal tunnel part of this.
Charles Goldfarb:That is totally fair. You know, I think what's so interesting is you could do scopes as a resident or a fellow. But this is absolute an acquired. You have to do enough of these to know what's normal, what's not normal, what to be looking for. And I think once you once you pass that learning curve, or get high enough on the learning curve, it becomes even more enjoyable because you know what you're seeing and you know what's normal and what's abnormal.
Chris Dy:Well brings to a close with how you assess the SL, the SL ligament whether that's through your three, four, whether that's through your mid carpal.
Charles Goldfarb:So assessing the SL should be done in a couple ways. For and this goes for the LT as well. You should assess from the radiocarpal joint and the radiocarpal joint you can look at the dorsal SL and the membranous portion of the cell. So that's dorsal and proximal you can't really see the volar SL. If you really want to see the volar SL you can make a volar radiocarpal portal near the FCR which is not hard. It is a little anxiety producing the first time you do it but you can use that portal. The other thing you have to do is look at the SL for the midcarpal portal. We know that the SL and LT are C shaped and so it's open distally is do you want to understand the relationship of two bones, and stability between the two bones by looking from distally. And so can you put a probe between the bones? Can you turn the probe? Can you drive the scope between the bones. But basically, you're looking directly at the ligament from the radiocarpal joint, and you're looking down at the interval from mid carpal joint. Those are the key steps. And there's some nuances such as using the mid carpal portal to assess the volar SL when there's worry about instability, but basically, I think the fundamentals are, if it looks good from the radiocarpal joint is highly unlikely you're going to find gross instability in the mid carpal joint. But if there's any concern from the radiocarpal joint assessment, you have to more carefully assess things from the radiocarpal from the midcarpal joint.
Chris Dy:Love it. And I'm going to bring it to a close with the most important question. Do you wear your loops when you do a wrist scope?
Charles Goldfarb:I absolutely do. I wear my loops when I do a femur fracture? I can't function without loops on isn't that odd? What about you?
Chris Dy:I wear them because I don't want to get any other eye protection? To be honest with you. It's just.
Charles Goldfarb:Yeah.
Chris Dy:Pragmatic reasons.
Charles Goldfarb:Yeah. And I think that if I end up doing an open repair, whether that's a foveal repair or an ECU sub sheath repair, I like to have them on. And so it's just part of my being a hand surgeon.
Chris Dy:The love of the hand, we use. So I hope I hope you found this enjoyable I have and hopefully people find it useful and tell us if you like hearing this kind of stuff, leave some comments and a review or email us or tell us on social media. Because we want to know if this is something that everybody wants to hear whether we should you know, shelf it. So.
Charles Goldfarb:Absolutely, I can promise you that if people do seem to like this, we will have to delve deeper in nerve topics I realized that I realized this was a gift to do arthroscopy first or sort of first, but I understand the realities of this process,
Chris Dy:A gift that you suggested. So treat yourself, Chuck.
Charles Goldfarb:Absolutely. All right. Have a great day.
Chris Dy:You too. Take care.
Charles Goldfarb:Hey, Chris, that was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is@congenitalhand. What about you?
Chris Dy:Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast.
Chris Dy:And be sure to leave a review that helps us get the word out.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time